MEDICARE: PAN PACIFIC PATHOLOGISTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	88CL74	HI

General Provider Information

NPI Number	:	1962479360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAN PACIFIC PATHOLOGISTS, LLC

Provider Business Mailing Address
First Line	:	33 LANIHULI ST
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96720-4142
Country	:	US
Telephone Number	:	808-935-4814
Fax Number	:	808-935-2518

Provider Business Practice Location Address
First Line	:	91-2135 FORT WEAVER RD
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-1929
Country	:	US
Telephone Number	:	808-677-7999
Fax Number	:	808-677-7990

Authorized Official
Title or Position	:	CEO
Name	:	MS. ALYSSA PARK
Credential	:
Telephone Number	:	808-680-7238

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	09/08/2008

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